- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $295.12 / $309.03
| Professional | | $288.40 | $295.12 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $302.00 / $831.76
| Professional | | $257.04 | $302.00 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $478.63 / $933.25
| Facility | | $407.38 | $478.63 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $446.68 / $512.86
| Professional | | $309.03 | $446.68 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $208.93 / $323.59
| Facility | | $151.36 | $208.93 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $457.09 / $478.63
| Professional | | $269.15 | $457.09 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $239.88 / $575.44
| Facility | | $151.36 | $239.88 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $549.54
| Professional | | $263.03 | $263.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $85.11
| Professional | | $50.12 | $54.95 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Professional | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $645.65 / $891.25
| Professional | | $302.00 | $645.65 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $1,659.59
| Facility | | $309.03 | $309.03 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $389.05 / $1,659.59
| Professional | | $309.03 | $389.05 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $616.60
| Facility | | $263.03 | $263.03 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $398.11
| Professional | | $302.00 | $302.00 | $398.11 |